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Big outcomes for Health Care Home Lakes extended care team patients


Connecting to health through comradery 

George, aged 70, had been disengaged with health services for a lot of his life. He didn't see the value in attending doctors' appointments.  "There's no meaning behind the doctor's appointment, you wait, the appointment is very hurried and they just give you a script," was his feeling.

In 2015, George was experiencing increasing poor health, poor mobility and was referred to the Health Care Home extended care team based in Taupō to help with his health management. Despite focussed care from the team, George still struggled to engage with the extended care team and his health was declining.

In 2018 George was re-referred to the extended care team as he was experiencing increased shortness of breath and high blood sugars. They arranged a package of care that included support from the dietician, exercise consultant and the nurse practitioner.

Shane Rakei, a peer support worker in the team runs an 'Off Highways' group consultation for truckers, who meet every fortnight. Shane invites GPs, dietician, nurse practitioner and clinical pharmacist input to the group consultation as required for 'light touch' health education and individual assessment. Two months ago, George was encouraged to join Shane's group after he had heard about Shane and how well some of the others in the group were doing.

Joining Shane's group has made a world of difference for George and his health. He particularly likes the comradery of the other drivers who attend and the relaxed atmosphere to talk about their health. Through attending the group it was discovered that George was in heart failure and had cellulitis of both lower legs, he is now being helped to manage his medications, checking in each fortnight to ensure he is self-managing his medications and health. George's legs have now improved so much he can join in with the early morning water walking exercise class, which the group also does fortnightly.


Image: Two members of the water walking exercise group enjoy a laugh together.

George's blood sugar levels have dropped and are now in single figures. He is now so engaged with his health that he has further appointments booked for an echocardiograph and spirometry. When asked about the group George only has good things to say. "Oh mate I tell you good, good and more good and I can now walk across the car park too."

Learning from peers

Six months ago Milton, aged 56, was referred to the Health Care Home extended care team in Taupō for support with diabetes, mobility and obesity issues. Milton had very little contact with health services for most of his life, ignoring his health and wellbeing, with no desire to seek medical help. The extended care team struggled to persuade him to accept their support.

It was not until he heard about Shane and the trucker group "Off Highways" that Milton started to engage and joined the group fortnightly meetings. In these groups, the health professionals were able to assess, treat and provide advice to Milton outside of the traditional practice setting and 1:1 environment.

Shane has also encouraged Milton to join his water walking exercise class. Milton's wife attends too and this flexibility fosters his success. As Milton says "he wouldn't do it without her." Over the last two months Milton has lost 4kgs and has lowered his blood sugar levels from double to single figures.


Image: Shane Rakei, Lakes extended care team peer support worker at his water walking class.

Through Shane's coaching and learning from others in the group, Milton now has a better understanding of his diabetes and has made a lot of changes to his diet and lifestyle. Thanks to the group, Milton's health is now being managed successfully and it is improving steadily to afford him a better quality of life.


About the Lakes extended care team

Pinnacle Midlands Health Network and Lakes DHB have together designed a new approach to provide co-ordinated packages of care for high-need patients enrolled in general practice.

The extended care team focus on better integration across our community to successfully deliver the Lakes DHB and general practice long-term condition management plan and support child health in Taupō and Turangi. 

We are here to support patients who have the greatest need. For GPs this means:
  • you will receive regular updates through our combined fortnightly interdisciplinary team meetings
  • we will support your year of care health planning
  • you will have guaranteed follow up in the community 
  • we will support a kaupapa M?ori approach through using our peer support and community health worker, and health coaching. 

The team

  • Clinical pharmacist
  • Peer support worker
  • Community health worker
  • Dietitian
  • Exercise consultant
  • Social worker
  • Community child health nurse
  • Health coach

Get in touch - we're here to help

The Lakes extended care team is making a difference for patients in the Taupō and Turangi areas. 
Contact one of the team if you would like to find out more.
  • Pen Blackmore- clinical manager, 07 376 2219
  • Krystal Thompson - locality administrator, 07 376 0060
  • Sonja Nielsen - administrator, community child health, 07 376 2208


How to make a referral?

We have set up a single point of entry eReferral for the whole extended care team, so all you need to do is open the eReferral form and complete the details as prompted, indicating the services you see fit. The team triages all referrals and will put in place the most effective shared care package for each patient.

About Health Care Home

Making good primary care, better

The Health Care Home is a primary health care model that gives patients more control, the practice team an environment where quality of care and innovation can flourish and enables truly proactive, coordinated care for those that need it most. It breaks down the professional and system barriers that we know prevent patients from getting the best care. Learn more on our dedicated website, www.healthcarehome.co.nz.




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